Outpatient Department Surveys

We have a diabetes clinic that has been a part of the hospital outpatient departments.  In the past it was not specifically listed as a site to be surveyed.  Do you recommend that this service be listed as a Joint commission site? When does TJC perform outpatient department surveys?

When Should Outpatient Departments be Included as a Site to be Surveyed?

Any clinic or service billed under your CCN as reported on your CMS form 855 should be included.

So, yes, your diabetes clinic should be listed.  It helps The Joint Commission determine how to structure the survey team, how many surveyors to send and more.  The diabetes clinic will likely not pose any vulnerability for you but here are a few points to consider. 

• Avoid having expired products
• Achieve low-level disinfection of surfaces between patients
• Display good glucometer QC management and cleaning
• Ensure privacy and rights statements are in order.

In addition, if there are medications it raises the risk somewhat. But, proper storage, no expired medications, refrigerator temperatures taken daily whenever meds are in the fridge and labeling meds properly, will mitigate those risks.

Patton Healthcare Consulting

Patton Healthcare Consulting provides a complete range of Joint Commission and CMS Compliance Assistance and a full range of pre-survey and post survey services.

We serve more than 350 hospitals, behavioral health care organizations, ambulatory clinics and home care companies nationwide—hospitals ranging from critical access hospitals to the largest health systems. Contact us at (888) PHC-INC1 for more information.